Gove states that, in future, the DfE wanted SCRs to focus on why professionals acted in the way they did and what prevented them taking the right action at the right time. For Gove, it is this kind of understanding that is necessary to reduce the risk of professionals in child protection repeating similar mistakes. Again, articulating the explanatory function
of SCRs with this clarity is radical – although this leaves aside the question of whether it is fair to judge the Edlington review by new standards to those that held at the time it was commissioned and conducted. Providing adequate explanations for poor professional performance after an accident has a long history in other high-risk industries such as aviation and, more recently, health. The central idea is that any worker’s performance is a result of both their own skill and knowledge and the organisational setting in which they are working. The nature of interactions between humans and diff erent aspects of the work environment make it more or less likely that high standards are achieved. Ascertaining which patterns of interaction
are problematic requires an in-depth understanding of technical work in context. One method to increase the reliability of performance and target so-called ‘error- producing conditions’ is known as a ‘systems approach’. Its adaptation for use in child welfare began in a project in 2005 led by the Social Care Institute for Excellence (Scie) and resulted in the Learning Together model (see Resources). Its use in case reviews is proving very promising. The requirement to use a systems approach for SCRs and other case reviews was one of the Munro Review’s recommendations and one that gained cross-government agreement. However, Gove’s input is the clearest articulation yet of the implications and it seems a strong indication of the political impetus to support this change. Importantly, when using a systems
approach, the kinds of explanations produced are not restricted to why professionals acted the way they did in particular episodes in the
Dr Sheila Fish is head of the Learning Together programme of work at the Social Care Institute for Excellence
24 SOCIALWORKMATTERS MAY12
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particular case. But that is only the fi rst step. Step two involves inferring what it tells us more broadly about how the multi-agency child protection system is working. A systems approach, such as Learning Together, moves you beyond the particularities of the single case into discussions about how similar scenarios and issues are normally managed and therefore whether the same issues are likely to happen again. In this respect an SCR is not a retrospective search for root causes but a prospective, future-oriented search for current weaknesses and strengths and future potential problems. The phrase coined by health academic Charles Vincent is that the case or incident acts as a ‘window’ on the system, revealing present gaps and inadequacies that might have an impact in future (see Resources).
When using a systems approach, the kinds of explanations produced are not
restricted to why professionals acted the way they did in particular episodes in the particular case
In his letter, Gove described new-look SCRs as part of a move to create ‘an open, confi dent, self-regulating system where professionals are continually asking how they can improve rather than a system clouded in secrecy’. The learning organisation has always been something of an ideal concept (Gould and Baldwin, see Resources) and the contradictions and challenges in any move towards this vision should not be underestimated. I have heard fear expressed by those in
strategic positions on LSCBs that this approach will hang them out to dry. This is a myth that needs correcting. Exploring systemic explanations for problematic practice is not simply a question of pushing blame to a diff erent place in the system. Taking a systems approach means moving beyond scapegoating any particular aspect of the system, be it a chief executive, director or an ICT programme. The aim is instead to gain a more nuanced understanding of underlying patterns of interactions that make up the system, which those accountable for quality are then expected to respond to. Meanwhile, the challenge to members of